Basic Information
| Provider Information | |||||||||
| NPI: | 1376911362 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KORTGARD | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | JOY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HANEL | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2618 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554112159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122011893 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1919 UNIVERSITY AVE W STE 200 | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551043435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512667999 | ||||||||
| FaxNumber: | 6512667850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2015 | ||||||||
| LastUpdateDate: | 01/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 21266 | MN | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 21266 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1255805800 | 05 | MN | MEDICAID |